The Shrubbery Surgery

We carried out an announced inspection at The Shrubbery Surgery on 01 November 2022.

Overall, the practice is rated as Requires Improvement.

Safe – Requires Improvement

Effective – Requires Improvement

Responsive - Good

Well-led - Good

Why we carried out this inspectionThis was an announced comprehensive inspection to provide the practice with an up to date rating. At our previous inspection on 06 August 2015, the practice was rated Good overall.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Shrubbery Surgery on our website at www.cqc.org.uk

How we carried out the inspectionThroughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing,
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider,
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider,
• A short site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as Requires Improvement overall

We rated the practice as Requires Improvement for providing Safe and Effective services.

We found that:

• Improvement was required in the monitoring of vaccine fridges.
• Our clinical record searches found improvement was required in relation to the safe management and monitoring of long-term conditions and high-risk medicines.

We rated the practice Good for providing well-led services.

We found that:

• The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of person-centre care.
• The practice exhibited an open culture, the leadership team were freely accessible to staff and staff felt included and listened to.

We found one breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

The provider should:

• Ensure that their newly improved and implemented procedures for patient group directives, high-risk medicines and long-term condition management are embedded.
• Continue to follow and embed revised procedures for the monitoring of oxygen and other emergency equipment at The Shrubbery site.
• Continue with their action plan to ensure that all historical safety alerts were being routinely reviewed.
• Follow up the proposal to appoint a Freedom to Speak Up Guardian.
• Continue with the plans to restart the Patient Participation Group (PPG).

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services